Summary Treatments for acute ischaemic stroke continue to evolve after the superior value of endovascular thrombectomy was confirmed over systemic thrombolysis. Unfortunately, numerous ...neuroprotective drugs have failed to show benefit in the treatment of acute ischaemic stroke, making the search for new treatments imperative. Increased awareness of the relevance of rigorous preclinical testing, and appropriate selection of study participants, might overcome the barriers to progress in stroke research. Relevant areas of interest include the search for safe and effective treatment strategies that combine neuroprotection reperfusion, better use of advanced brain imaging for patient selection, and wider implementation of prehospital conducted clinical trials. Randomised controlled trials of combination treatments completed within the past 5 years have included growth factors, hypothermia, minocycline, natalizumab, fingolimod, and uric acid; the latter two drugs with alteplase produced encouraging results. Blocking of excitotoxicity is also being reassessed in clinical trials with new approaches, such as the postsynaptic density-95 inhibitor NA-1, or peritoneal dialysis to remove excess glutamate. The findings of these randomised trials are anticipated to improve treatment options and clinical outcomes in of patients with acute stroke.
Summary Background The REVASCAT trial and other studies have shown that the neurovascular thrombectomy improves outcomes at 90 days post stroke. However, whether the observed benefit is sustained in ...the long term remains unknown. We report the results of the prespecified 12-month analysis of the REVASCAT trial. Methods Patients with acute ischaemic stroke who could be treated within 8 h of symptom onset were randomly assigned to medical therapy (including intravenous alteplase when eligible) and neurovascular thrombectomy with Solitaire FR or medical therapy alone. The main secondary outcome measure at 1 year follow-up was disability, measured using the modified Rankin Scale (mRS), ranging from 0 (no symptoms) to 6 (death) with categories 5 (severe disability) and 6 (death) collapsed into one category (severe disability or death), analysed as the distribution of the mRS. Additional prespecified secondary outcome measures included health-related quality of life measured with the EuroQol five dimensions questionnaire (EQ-5D) utility index (ranging from −0·3 to 1, higher values indicate better quality of life), the rate of functional independence (mRS 0–2), and cognitive function measured with the Trail Making Test (reported elsewhere). Treatment allocation was open label but endpoints at 12 months were assessed by masked investigators. The trial was registered at ClinicalTrials.gov , number NCT01692379. Findings From Nov 24, 2012, to Dec 12, 2014, 206 patients were randomly assigned to medical therapy plus endovascular treatment (n=103) or medical treatment alone (n=103), at four centres in Catalonia, Spain. At 12 months post randomisation, based on 205 of 206 outcomes available at 12 months, thrombectomy reduced disability over the range of the mRS (common adjusted odds ratio aOR 1·80, 95% CI 1·09–2·99), and improved functional independence (mRS=0–2; 45 44% of 103 patients vs 31 30% of 103 patients; aOR 1·86, 95% CI 1·01–3·44). Health-related quality of life was superior in the thrombectomy group (mean EQ-5D utility index score, 0·46 SD 0·38 in the thrombectomy group vs 0·33 0·33 in the control group, difference 0·12 95% CI 0·03–0·22; p=0·01). 1-year mortality was 23% (24 of 103 patients) in the thrombectomy group versus 24% (25 of 103 patients) in the control group. Interpretation At 12 months follow-up, neurovascular thrombectomy reduced post-stroke disability and improved health-related quality of life, indicating sustained benefit. These findings have important clinical and public health implications for evaluating the cost-effectiveness of the intervention in the long term. Funding Fundació Ictus Malaltia Vascular through an unrestricted grant from Medtronic.
A 29-year-old male patient with aphasia and mild weakness of the right arm arrived at the emergency room 4 hours after symptom onset. The computed tomography perfusion showed a typical delay in the ...time-based maps in the left occipital lobe and another hyperperfused area in the left frontal lobe. The follow-up magnetic resonance imaging confirmed cortical ischemic lesions in both areas. This case shows that besides hypoperfusion, hyperperfusion can also be found in the first stages of acute stroke, and it is highly suggestive of established ischemic lesions.
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